What is the recommended treatment for hypertension?

Recommended Treatment for Hypertension

For most adults with confirmed hypertension, initiate combination therapy immediately with two first-line agents—specifically a RAS blocker (ACE inhibitor or ARB) combined with either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination, while simultaneously implementing lifestyle modifications targeting weight loss, sodium restriction, and regular physical activity. 1, 2

Treatment Thresholds and Risk Stratification

When to Start Pharmacological Treatment:

• Begin drug therapy immediately for sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 3
• For BP 140-159/90-99 mmHg, initiate treatment based on presence of target organ damage, cardiovascular disease, diabetes, or 10-year cardiovascular disease risk >15% 3, 2
• For BP 130-139/80-89 mmHg (prehypertension), calculate 10-year cardiovascular risk to guide treatment intensity 2

Lifestyle Modifications (Foundation for All Patients)

All hypertensive and borderline hypertensive patients require non-pharmacological interventions: 3

• Weight reduction: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) through reduced fat and total calorie intake 3, 2, 4
• Sodium restriction: Limit intake to <2,300 mg/day; eliminate excessively salty processed foods 1, 4
• Dietary pattern: Consume 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 1
• Physical activity: Minimum 150 minutes/week of moderate-intensity aerobic exercise (brisk walking) or 75 minutes/week vigorous activity, plus resistance training 2-3 times weekly—predominantly dynamic rather than isometric 3, 2
• Alcohol limitation: ≤2 drinks/day for men and ≤1 drink/day for women 1, 4
• Tobacco cessation: Complete elimination with referral to smoking cessation programs 1
• Sugar elimination: Remove sugar-sweetened beverages and restrict free sugar to maximum 10% of energy intake 1

These modifications are partially additive and enhance pharmacologic efficacy, potentially reducing the number or dose of medications required. 4, 5

First-Line Pharmacological Treatment Algorithm

Step 1: Initial Two-Drug Combination 1, 2

Start with a RAS blocker (ACE inhibitor or ARB) PLUS one of the following:

• Dihydropyridine calcium channel blocker (preferred combination), OR
• Thiazide/thiazide-like diuretic

Prescribe as a single-pill fixed-dose combination whenever possible to improve adherence. 2

Step 2: Escalation to Triple Therapy 1, 2

If BP remains uncontrolled after 4 weeks, escalate to:

• RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
• Again, preferably as a single-pill combination

Step 3: Resistant Hypertension Management 2

Add agents sequentially: beta-blocker, alpha-blocker, aldosterone antagonist, direct vasodilator, or centrally acting alpha-2 agonist 6

Critical Pitfall: Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit. 2

Blood Pressure Targets

Standard targets for most patients: 1, 2

• Adults <65 years: Systolic 120-129 mmHg and diastolic <80 mmHg if well tolerated
• Adults ≥65 years: Systolic 130-139 mmHg
• Minimum acceptable control (audit standard): <150/90 mmHg 3

High-risk populations require more aggressive targets: 2

• Diabetes: <130/80 mmHg 1, 2
• Chronic kidney disease: Systolic 120-129 mmHg if tolerated (for eGFR >30 mL/min/1.73m²) 1, 2
• Coronary artery disease: <130/80 mmHg 2
• Previous stroke/TIA: Systolic 120-130 mmHg 2

Achieve target BP within 3 months of initiating treatment. 1

Special Population Considerations

Black Patients:

Initial therapy should include a thiazide-like diuretic plus calcium channel blocker, or CCB plus ARB (not ACE inhibitor alone, which has smaller BP effects as monotherapy in this population). 2, 7, 4

Note: The stroke reduction benefit of losartan in patients with left ventricular hypertrophy does not apply to Black patients. 7

Patients with Albuminuria/Proteinuria:

RAS blockers are first-line treatment due to superior albuminuria reduction beyond BP lowering alone. 1, 2

Diabetic Nephropathy (Type 2 Diabetes):

Losartan specifically reduces progression of nephropathy (measured by doubling of serum creatinine or end-stage renal disease) in patients with elevated serum creatinine and proteinuria (urinary albumin-to-creatinine ratio ≥300 mg/g). 7

Heart Failure with Preserved Ejection Fraction (HFpEF):

Add SGLT2 inhibitors for symptomatic patients. 1

Heart Failure (General):

Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists; consider ARNI as alternative to ACE inhibitor/ARB. 2

Elderly or Diabetic Patients:

Measure standing BP to exclude orthostatic hypotension. 3

Proper Blood Pressure Measurement Technique

Essential for accurate diagnosis: 3

• Use a validated, properly maintained and calibrated device
• Patient seated with arm at heart level
• Adjust bladder size for arm circumference
• Deflate cuff at 2 mm/s, measure to nearest 2 mm Hg
• Record diastolic pressure as disappearance of sounds (phase V)
• Take at least two measurements at each of several visits to determine treatment thresholds

Ambulatory BP monitoring indicated when: 3

• Clinic BP shows unusual variability
• Hypertension resistant to three or more drugs
• Symptoms suggest hypotension
• Suspected "white coat hypertension"

Adjunctive Cardiovascular Risk Reduction

Beyond BP control, consider: 3

• Aspirin for appropriate cardiovascular risk profiles
• Statins for lipid management as part of comprehensive cardiovascular risk reduction

Monitoring and Long-Term Management

• Medication timing: Prescribe at the most convenient time to establish routine and improve adherence 1
• Laboratory monitoring: Check renal function and potassium at least annually when using ACE inhibitor, ARB, or diuretic 1
• Annual cardiovascular risk reassessment 2
• Home BP monitoring: Use both office and home readings for ongoing assessment 2
• Lifelong treatment: Continue BP-lowering therapy indefinitely if well tolerated, even beyond age 85 1, 2

Key Clinical Pitfalls to Avoid

• Starting with monotherapy instead of combination therapy delays BP control and increases cardiovascular risk 1, 2
• Using multiple separate pills instead of single-pill combinations reduces adherence 2
• Failing to measure standing BP in elderly/diabetic patients misses orthostatic hypotension 3
• Combining two RAS blockers increases harm without benefit 2
• Discontinuing lifestyle modifications once medications are started reduces overall efficacy 4, 5